Vertical vs. Horizontal Approach: The drawbacks of each and a need for a merging or “diagonal” approach

When thinking about how to address health problems around the world there were two ideas that seem to arise, vertical and horizontal approaches. The vertical approach being a disease specific top-down approach that makes it easier to obtain funding and measure results and the horizontal approach being a more comprehensive approach that seeks to treat all the underlying issues a population that cause various diseases and health problems but that is more abstract.

These approaches are also intrinsically related to the debate of Magic Bullets vs. Primary Care and even in the debate of Comprehensive Primary vs. Selective Primary Care. The vertical model relies on the use of magic bullets, simple and fast acting biomedical advances, in order to implement their programs. When a so-called magic bullet is available and completely effective a vertical approach would be successful as you can reach many people give them a one-time treatment and solve the specific health problem.

The issue arises because there doesn’t exist a magic bullet for the vast majority of diseases that developing countries face, therefore when global health organizations come into these countries with specific disease approaches they are overlooking the structural factors that give rise to health concerns. Comprehensive Primary Care aims to be the opposite of this; it is basically a horizontal approach. The issue there, of course are concerns over cost-effectiveness. Quick-fix and Magic bullet programs come out with a much better ranking in regards to cost-effectiveness which favors downstream medical interventions and finds upstream interventions, such a school-based programs largely ineffective, because it will take several years for the health effects to take place and even when they do it is not easily measurable.

You see this sort of idealistic approach and mentality at the Alma-Ata conference in 1975, with the desire of “Health Care for all by year 2000”. But this model was ultimately unsuccessful and the Selective Primary Care Model that emphasized GOBI (growth monitoring, oral rehydration therapy, breast feeding and Immunizations) triumphed. Selective Primary Care operates more as a vertical approach even primary care in the name because it emphasized only specific issues. While it was an “interim” strategy there were never plans of shifting to more comprehensive primary care.

These two approaches seem like they would have to be competing ideologies, where only one can be correct. I believe that this is not necessarily true. Because both of these approaches have considerable drawbacks and unintended consequences of implementation, the merging of both these approaches would actually increase the benefits while minimizing the risks and drawbacks. In an article by Gorik Ooms, he addresses this as a need for a “diagonal” approach. He suggests that we should be aiming for “disease-specific results but through improved health systems”. This is an interesting idea and definitely important to consider when planning and designing interventions. I believe it is possible to create a new approach that will be more effective; it will however require funding and commitment. Tore Godal suggests the shifting to a Global Health fund that would “consolidate towards a global health fund with one health sector funding channel”. He argues that with an increase in funding and supplies it is possible through a unified effort to simultaneously achieve disease-specific success while strengthening the health system.

Gijs Elzinga also discusses this in an editorial piece titled “Vertical-horizontal synergy of the health workforce” in which he states that while certain components of vertical programs are vertical in nature there is an interface when it comes to the delivery of interventions. Because intervention delivery requires the greatest number of workforce involvement, there is some room for the interventions to be more integrated into a horizontal system, in which health care workers seek to address all the issues. I think vertical approaches can enhance vertical horizontal collaborations and attempt to decrease the polarization of the vertical vs. horizontal debate. The use of more of the existing personnel of healthcare workers is one way this can be achieved.

I believe the strength in this idea of a “diagonal approach” comes from not shifting to a horizontal approach overnight and the integration of the benefits of each. It is important to change the mentality around our approach as only being able to fit into these categories. Although pragmatism is important when it comes to implementation, we need to think about the long-term results and the programs sustainability. We need to implement programs that have the ability to change over time, shifting its goals with increasing resources.

Sources from Class:

Paul Farmer, e. A. (2013). Reimagining Global Health An Introduction.

Cueto 2004 The Origins of Primary Health Care and Selective Primary Health Care. American Journal of Public Health 94(11)1864-74

Do you think merging the different approaches that we have discussed will yield successful outcomes? Do you think it is possible to implement programs like this?

Do you think the idealism of the Alma-Ata Declaration was influential in making change by getting people to talk about health, or did its lack of pragmatism and ability to be implemented render it basically useless?

13 thoughts on “Vertical vs. Horizontal Approach: The drawbacks of each and a need for a merging or “diagonal” approach”

Thanks for the clear discussion of vertical and horizontal health approaches. How do you suggest securing this Global Health Fund that Godal writes about?

I am also curious about the logistics of a diagonal approach, like you mention in your first question. One way I picture a diagonal approach working is by starting with a more vertical approach. I would start with a disease specific goal to raise funds (it is usually easier to donate to a specific cause than the general improvement of health of a group of people) and find a community that fits this goal. I would also encourage those who are working on this project to partner with the community so that together, once the health workers are there and have established their legitimacy and desire to help, they can come up with general health goals and needs in partnership with the community (and the health practitioners of the community). In this way, I could see the health workers arriving with funding secured for a start of a more vertical intervention, then staying longer than other vertical interventions to work on the more broad issues that are at the root of many healthcare issues. This is just one idea of an attempt at a diagonal approach and I am interested to hear what others have to say!

Hi Yilena,
I think your idea of combining horizontal and vertical approaches makes a lot of sense. I think the struggles of each approach could be counteracted by the other if they were implemented together. Although the implementation of both could face the struggle of ‘cost effectiveness’ and being able to acquire the necessary funding/resources, if they were successfully realized in a community in unison I think there could be tremendous health outcomes.

One way the two approaches could be carried out is first a horizontal approach followed by more vertical approaches. First, the implementation of primary health care in a community, with nutrition, sanitation, vaccines, etc could eliminate many diseases such as water born illnesses and diseases that can be prevented through vaccines. After the successful actualization of primary health care in a region, the community can then examine and address the health problems that have yet to be resolved by the primary health care initiative. In this way, communities can choose their own problems they want to address and the issues that are most important to them. Once they have targeted the health problems they want to address, they could hopefully secure the necessary funding that would allow them to eradicate or control the specific health issue through a specific, targeted vertical approach.

Hi Yilena,
I enjoyed your post on diagonal approaches to medical issues in developing countries. You gave a lot of important insights on how to smoothly transition into creating a program that incorporates both horizontal and vertical approaches. Something that you mentioned was the need to pour in financial investment into these projects, but who would these investors be? Would the money be coming form the country’s own government or a foreign aiding government? I think that when a foreign government gets involved with financial allocations of a project there is a danger with the foreign country creating a system that addresses the needs that they think are important but may not actually be important to the country. Much like the system that was implemented in Adia Benton’s book of HIV Exceptionalism, there may be a confusion of priorities that comes with an air of paternalism. However, for many of these low-income countries foreign aid may be the only option, which leads to a difficult decision between obtaining financial resources and risking foreign paternalism.

Hello Yilena,
Great post about suggesting a “diagonal” alternative to the very polar vertical and horizontal approaches! I am intrigued by this idea of diagonal funding, and like Methma and Silvia, I wonder the mechanisms by which funding would undergo such vertical to horizontal transitions. Though a potential solution to solving polarization of the “magic bullet” vs. primary care intervention debate, I think the diagonal approach takes this assumption of investor commitment. At a certain point, donors want to see that expenditure of their money makes an outcome. If the Global Fund funnels some of their money into health systems and some of their money into direct medical intervention, then there may be tangible results on the disease front but there may be obscure or readily unavailable improvement in health systems. Essentially, how do you get aid to “buy into” this idea (it is already difficult for aid to “buy into” the horizontal approach)?
Moreover, there is a question of who gets the authority in assessing improvement. Established health systems in developed countries are fueled by ideology, and our countries’ health systems reflect a geopolitical ideology. So, who gets to decide if the developing country should expand their workforce or improve workforce training or strengthen their health insurance programs or improve their laboratory research? In a diagonal approach, does foreign aid have jurisdiction over domestic resources or does the government itself have jurisdiction? And if the foreign aid doesn’t have jurisdiction, how do we know if funding is going towards its intended purposes of developing health systems?

Thank you for your insightful post. I think finding the middle ground between a purely vertical approach and a purely horizontal approach can be beneficial as a ‘horizontal’ approach allows for combining the benefits of each of the former approaches and the elimination of the drawbacks of the same. I believe merging the vertical and horizontal approaches can yield successful outcomes. I think one of the ways to make this work would be to use a circumstance that calls for a vertical intervention, such as an epidemic, to create a response program that is ‘diagonal’. I fancy Methma’s suggestion which extends a largely vertical program into a horizontal one.

As for the usefulness of the idealistic Alma-Ata Declaration, I think it served as an overall framework for the pragmatic programs that followed. I feel that while broad strokes ideas like those outlines in the Declaration do not translate into concrete results, they serve an important purpose of bringing countries and other actors together in order to engage in discussion and get the ball rolling. In some ways they pave the way for smaller, implementation friendly programs which can then chip away at the goals of the larger abstract program.

I enjoyed reading your topic about different approaches to health care. It was indeed thought provoking. As it is evident by your blog and the experience from all the previously tried and tested approaches, we are ever more confused now than we were before in terms of picking the right approach to delivering health care. This stems from all the variables that play a role in determining the ultimate outcome and the variabilities that exist in the definition of outcome itself.

I would like to address this in the present context of health care reforms that are occurring in our own country. Was providing health care to everyone the only goal of ObamaCare? If that were to be the case, then the government could have arranged for everyone to have health insurance just as easily as they issue social security numbers to all eligible people of the United States. As you can see, it would be a straightforward vertical approach to one of the basic problems of delivering healthcare and the problem would be essentially resolved. But in reality, it is not so simple. We are not even talking about delivery of health care, wellness or eradication of any particular disease. We are just talking about providing insurance so that the recipients can then address their health issues and plan wellness, and we are failing in reaching that goal by far. This is because every task has a process, and every process, a procedure, all of which entails rules and regulations, pros and cons, and ultimately many stakeholders with their own personal agendas and cost factors. So, this makes what seems like a very easy task almost impossible to accomplish.

Based on my example it is very clear that a simple approach, be it vertical or horizontal, is not going to be sufficient to achieve any of the health care goals. In fact it cannot be a linear approach at all regardless of which direction the line is moving. It would have to be a multifaceted approach, as I am convinced that there are too many interconnecting variables, causes, and effects that need to be fused together to see the end product reach fruition. This is what makes the job challenging and, unfortunately, oftentimes leads to failure.

Hi Yilena, you bring up some very comprehensive strategies for dealing with health problems in your blog post. The diagonal approach to health care does seem to be the most effective in yielding both short and long term success.

However, the implementation of diagonal programs will
require careful thought and planning. I enjoyed reading Methma’s approach and think that using a specific disease to strengthen the overall health care system is a strong approach to diagonal health care. When targeting a specific disease, we should use the funds to not only implement the “magic bullet” cure, but also strengthen hospital infrastructure and train health workers to ensure that other diseases will not devastate the population in the future. Programs should take a two tier approach and focus on short term impact and long term stability.

In regards to the second question, the Alma-Ata Declaration was a positive step forward in the field of global health because it established a common framework and goals for nations to follow. Though it was practically useless, it reinforced the idea that we as a global society, care about the health and dignity of all human beings. I have hope that one day, we will work towards more concrete and definitive goals towards ensuring human health.

I also wonder how we will be able to market diagonal care so that it still appeals to foreign aid agencies. It should maintain the “concrete goals” of vertical intervention, while incorporating the long term sustainability and holistic nature of horizontal care.

I believe that the Alma-Ata Declaration had both positive and negative effects. Although the Alma-Ata itself ended up being a failure, it got people taking about more specific ways to target the issues at hand. The secondary healthcare movement was led by a smaller group of individuals in rebellion to Alma-Ata. It had achievable goals and ended up being more successful. However, if the Alma-Ata had not taken place the creation of the secondary movement probably would not have happened. Therefore, I definitely believe that idealism is important because, although abstract, it serves as inspiration for smaller more effective movements.

On the other hand, I think idealism can be desensitizing. The Alma–Ata had such grandiose promises that were unaccomplished. Even worse, a specific date was set where all these goals would be fulfilled. I think promising dates in this manner is not a good idea. It is especially disappointing. It also makes it less likely that people will take these initiates seriously the next time, even if the goal is way more achievable.

I feel like a lot of the issue with a diagonal approach is that it is hard to imagine. Vertical and Horizontal programs are very different in nature, so how do you combine them? Even if you combine them would it even be effective? You talk about Gijs Elzinga theory for combining these two approaches. With these methods, “health care workers would be able to address all the issues.” However, that sounds overwhelming. Addressing so many issues at once in one large effort could end up being mediocre similar to the idealistic goals of primary health care.

Thank you for your post about vertical and horizontal approaches, and the possibility of combining the two as a model for more long-lasting interventions. In my opinion, these approaches are just that–models. The realities of going into a country and doing global health work almost never fit a model, and so as much as organizations can plan interventions on the grounds of theoretical approaches, we can only really learn from experience. In order to receiving funding, making an intervention appear vertical might be necessary; eradication of a disease is often sexier than increasing someones overall quality of life. Once the program is established, and improved outcomes because of their work are proven to funders, then an intervention can expand its scope and take a more horizontal approach. I think that Methma and Divya were right in their ideas about two-tiered approaches, because this is both attractive to funders, but also can create long-term change.

I think that the idealism of the Alma-Ata Declaration was necessary–a grand vision gives people hope and something to work towards. Though it was not what was needed at the time, I think it is being used today in many ways as a manifesto of the new primary health care movement. The idea of health being a human right has come up as an issue again during the debate over health care in our own country, and I think having the Alma-Ata Declaration as a precedent is helpful and necessary.

Thank you all for your insightful comments! It really got me think more about the issues that arise with any approach and the difficulty of the approach I suggest in particular. I don’t think it is possible for me to have concrete answers to some of these questions as they are very complex and don’t have one simple answer that can be easily implemented. I definitely agree with Shreya that I ended up even more confused as to which is the right approach, which so many factors and previous examples of successes and failures to consider.
I think going about the diagonal approach while it aims to avoid some of the problems of both the vertical and horizontal approach also has some of the same challenges. Many of you asked about the difficulty of securing funding and the “buy-in”. This is where the vertical approach triumphs. I believe it would be good to, in essence, pick the benefits from each. Last class, we discussed Partners in Health and this topic came up again. We talked about the way they are addressing this issue of needing funding and “buy-in” not only from the donors but also from the community. How do you get people to come in for primary care, to get their blood pressure taken? PIH focuses on 4 major categories that are well known relatively easy to treat problems such as TB and HIV. This gets donors to donate money to help diseases that can have very much quantitative and measurable outcomes and results. They would be encouraged to keep donating by the falls in disease rate and by very moving “magic bullet” type stories. The community is also aware of the treatment options available for these types of diseases so they would come in to the clinic to get tested and receive treatment . I think at this point it would be possible to integrate the two approaches, setting up a system of primary care and horizontal concerns within a more vertical model that is more effective in terms of getting donors as well as getting people into the clinic after which we can have primary care doctors and more general health workers to help address the underlying causes of a lot of these diseases as well as work on preventative medicine. It is definitely not a simple task and I do not believe to be only one concrete answer but rather each situation and location where interventions are attempted need to be analyzed separately using both models as well as history of successful and unsuccessful projects and trying to better help and account for unintended consequences.

Hey Yilena,
Great point about getting the community to “buy in.” It’s a curious situation particularly when you have altruistic foreigners who really want to help and improve health, but an international community who may not care for your interventions. I think it ties back to this idea of social realities and avoiding paternalism in health interventions. For instance, maybe we want to build health centers, but the community might just want a reliable, clean source of water. As you said, our interventions need to be specific and location based. In part this involves bringing in culturally competent foreign aid workers and including community health workers. Just as medical interventions should follow a diagonal approach, ownership of a health outcome needs to follow a diagonal approach such that a community eventually has complete sovereignty over its health system.

Hi Yilena,
Thank you for your insightful post on vertical, horizontal, and diagonal health approaches and for your update discussing how buy-in from the community is just as critical as buy-in from donors, even though incentivizing members of the community is often overlooked. I agree with what you and other commenters have been saying that the most feasible way to achieve a horizontal health outcome is to take a vertical approach at first and gradually expand the program, to facilitate both community and donor buy-in. However, I worry about people who have goon intentions in beginning a vertical program with the goal of making it a diagonal program but never getting the chance to. I also appreciate your comments about needing to ensure that each intervention is analyzed on an individual basis.

However, on the whole, I believe that attempting to tackle to underlying economic, biosocial, and political forces that are setting the stage for a health crisis to intervene as just as critical as treating any disease and it feels unethical to purposefully wait to address these factors until “later.” I view immediate horizontal approaches as the goal of all interventions, and think diagonal approaches should only be used in situations in which immediately implementing a horizontal approach is completely infeasible (because of funding or other infrastructure barriers). If people being to set up their interventions as a horizontal model, hopefully we can avoid outcomes like what happened in places that implemented selective primary health care, who meant to transition to comprehensive PHC but were unable to.